How To Use CPT Code 81500

CPT 81500 describes the biochemical assays of two proteins, CA-125 and HE4, for oncology (ovarian) patients. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes and billing examples.

1. What is CPT Code 81500?

CPT 81500 can be used to describe the biochemical assays of two proteins, CA-125 and HE4, for oncology (ovarian) patients. This code is used when these assays are performed on a patient’s serum to determine their risk score using an algorithmic analysis. It is important to note that CPT 81500 should not be reported in conjunction with CPT codes 86304 and 86305.

2. Official Description

The official description of CPT code 81500 is: ‘Oncology (ovarian), biochemical assays of two proteins (CA-125 and HE4), utilizing serum, with menopausal status, algorithm reported as a risk score.’

3. Procedure

1. The lab analyst performs biochemical assays for CA-125 and HE4 using the patient’s serum.
2. The lab analyst inputs the test results along with the patient’s menopausal status into a computer program.
3. The computer program utilizes a specific algorithm to analyze the data and generate a risk score called ROMA (Risk of Ovarian Malignancy Algorithm).
4. The lab analyst reports the risk score to the healthcare provider.

4. Qualifying circumstances

CPT 81500 is used for oncology (ovarian) patients who require biochemical assays of CA-125 and HE4 proteins. These tests are performed to determine the patient’s risk score using an algorithmic analysis. It is important to note that CPT 81500 should not be reported in conjunction with CPT codes 86304 and 86305.

5. When to use CPT code 81500

CPT code 81500 should be used when performing biochemical assays of CA-125 and HE4 proteins for oncology (ovarian) patients. It is important to note that this code should not be reported in conjunction with CPT codes 86304 and 86305.

6. Documentation requirements

To support a claim for CPT 81500, the following documentation is required:

• Patient’s diagnosis and indication for the biochemical assays
• Results of the biochemical assays for CA-125 and HE4 proteins
• Patient’s menopausal status
• Algorithmic analysis and the reported risk score

7. Billing guidelines

When billing for CPT 81500, it is important to note that this code should not be reported in conjunction with CPT codes 86304 and 86305. Medicare and some other payers may not accept CPT 81500 and may require billing only the underlying test codes. It is recommended to use the unlisted MAAA code, 81599, only when there is no Category I or administrative code available for a specific MAAA test.

8. Historical information

CPT 81500 was added to the Current Procedural Terminology system on January 1, 2013. There have been no updates to the code since its addition.

9. Examples

1. A patient with suspected ovarian cancer undergoes biochemical assays for CA-125 and HE4 proteins. The algorithmic analysis using the patient’s menopausal status generates a risk score indicating a high likelihood of malignancy.
2. An oncology patient with a history of ovarian cancer receives regular monitoring through biochemical assays for CA-125 and HE4 proteins. The algorithmic analysis reports a risk score indicating a low likelihood of malignancy.
3. A patient with a family history of ovarian cancer undergoes biochemical assays for CA-125 and HE4 proteins. The algorithmic analysis, considering the patient’s menopausal status, generates a risk score indicating an intermediate likelihood of malignancy.
4. An oncology patient with a suspicious ovarian mass undergoes biochemical assays for CA-125 and HE4 proteins. The algorithmic analysis, along with the patient’s menopausal status, generates a risk score indicating a high likelihood of malignancy.
5. A postmenopausal patient with symptoms suggestive of ovarian cancer undergoes biochemical assays for CA-125 and HE4 proteins. The algorithmic analysis reports a risk score indicating a low likelihood of malignancy.
6. An oncology patient with a history of ovarian cancer undergoes biochemical assays for CA-125 and HE4 proteins. The algorithmic analysis, considering the patient’s menopausal status, generates a risk score indicating a high likelihood of malignancy.
7. A patient with a suspicious ovarian mass undergoes biochemical assays for CA-125 and HE4 proteins. The algorithmic analysis, along with the patient’s menopausal status, generates a risk score indicating an intermediate likelihood of malignancy.
8. An oncology patient with a family history of ovarian cancer undergoes biochemical assays for CA-125 and HE4 proteins. The algorithmic analysis reports a risk score indicating a low likelihood of malignancy.
9. A postmenopausal patient with symptoms suggestive of ovarian cancer undergoes biochemical assays for CA-125 and HE4 proteins. The algorithmic analysis generates a risk score indicating a high likelihood of malignancy.
10. An oncology patient with a history of ovarian cancer undergoes biochemical assays for CA-125 and HE4 proteins. The algorithmic analysis, considering the patient’s menopausal status, generates a risk score indicating a low likelihood of malignancy.